Download counselling geriatric patients

C E C O M P L I A N C E C E N T R E N AT I O N A L C O N T I N U I N G E D U CAT I O N P RO G R A M • O C TO B E R 2 0 0 4
>Statement
of Objectives
After reading this lesson you will be
able to:
1. Identify the need for special counselling
attention in geriatrics
2. List factors contributing to drug-use
problems in the elderly
3. Describe specific factors affecting
medication adherence by the elderly
4. Describe the issues in dealing with
geriatric patients
5. List different techniques and tools to
assist counselling geriatric patients
www.novopharm.com
COUNSELLING
GERIATRIC PATIENTS
by Melanie Rantucci, M.Sc.Phm., Ph.D
1. INTRODUCTION
>Instructions
1. After carefully reading this lesson, study
each question and select the one answer
you believe to be correct. Circle the appropriate letter on the attached reply card.
2. Complete the card and mail, or fax to
(416) 764-3937.
3. Your reply card will be marked and you
will be advised of your results in a letter
from Rogers Publishing.
4. To pass this lesson, a grade of 70%
(14 out of 20) is required. If you pass, your
CEU(s) will be recorded with the relevant
provincial authority(ies).
(Note: some provinces require individual
pharmacists to notify them.)
1 CEU
Approved for 1 CE unit by the
Canadian Council on Continuing
Education in Pharmacy.
File # 137-0604
Case 1:
CK is a 76-year-old woman who receives
nine different medications every three
months from pharmacist BB. She suffers
from diabetes, CHF, arthritis, COPD, constipation and cataracts, and is a little hard
of hearing. She seems frail and unsteady on
her feet and most often receives her prescriptions by delivery. She calls the pharmacy to ask about a refill for one of her
inhalers but seems unclear about which one
she needs (she uses both salbutamol and
orciprenaline). BB asks her to describe the
colour and is able to identify it as the salbutamol, but notices in her record that she
received it the previous week. CK sounds
annoyed when the pharmacist tells her this
and insists she did not get it. BB becomes
annoyed also and says he will send another
out but that CK should keep better track of
her medications in future.
Pharmacists deal with elderly patients
like CK more than any other patient age
group.1 This is a fast-growing group —
3.92 million Canadians over 65 in 2001
(about 12% of the population), expected
to reach 6.7 million in 2021 and 9.2 million in 2041 (25% of the population).4
The proportion of Canadians over 85
years of age is growing even faster, with
430,000 in 2001 expected to reach 1.6
million (4% of the population) by 2041.4
Seniors consume 28 to 40% of all prescription medications in Canada.1
Canadian studies report that three-quarters of seniors have taken a medication in
the previous two days, up to an average
of eight medications per day.2,3 This
extensive use of medications by seniors is
partly a result of the increasing morbidity that occurs with aging. On average,
geriatric patients have six co-existing
conditions, more often chronic (reported
in 80%) than acute.1,4,5
Of particular concern to pharmacists is
the inappropriate use of these medications
and drug-related problems (DRPs). DRPs,
including drug interactions, adverse drug
reactions (ADRs), lack of effect or excess
effects and unnecessary use of medications,
have been reported in up to 75% of seniors.9 This results in six to 28% of hospital
admissions, as well as physician visits, drug
therapy, ER visits, long-term care admissions and ultimately deaths, at an estimated cost of $11 billion.3,8
From 16 to 73% of medications used
by seniors have been shown to be inappropriate, resulting from noncompliance and
inappropriate prescribing.6 Studies in the
elderly indicate that age does not appear to
have an effect on compliance, however
complexity of drug regimen and patient
comprehension do affect compliance.7
Inappropriate prescribing has been
more recently investigated as a factor in
2
COUNSELLING GERIATRIC PATIENTS
DRPs. A Canadian study of communitydwelling seniors found that nearly onefifth (16.3%) receive at least one potentially inappropriate medication. Other studies
have reported from four to 53%.3,9
Many of these problems are preventable (12% in a recent study of hospital
admissions in Canada), creating an
important role for pharmacists.10
A number of strategies have been proposed to reduce preventable drug-related
problems (PDRPs) in seniors, including
seamless-care programs linking hospitaland community-based pharmacists (to be
discussed in future lessons) and improved
communication between the patient and
pharmacist to monitor and provide
advice.8 To fulfill this role, pharmacists
need to understand factors affecting
drug-use problems in the elderly, how to
deal with elderly patients and effective
ways to counsel them.
FACTORS AFFECTING DRUG-USE
PROBLEMS IN THE ELDERLY
MANY FACTORS CREATE AN INCREASED RISK
for DRPs in the elderly, involving both
patient and physician issues. Patient
issues such as the “pharmaco-uniqueness”of geriatric patients have been recognized as most important, along with
compliance, co-morbidities, polypharmacy communication and cultural issues.8
Physicians’ issues such as their lack of
time, knowledge of medications, and
inappropriate prescribing and access to
care have also been noted as potential
contributing factors for DRPs.
Patient Issues: The elderly are a heterogeneous group. Physiologic and cognitive changes that come with aging occur to
different degrees and at different rates. To
FACULTY
CE COMPLIANCE CENTRE • OCTOBER 2004
varying degrees, aging results in physiologic changes to the gastrointestinal system
(GI), fat and muscle distribution, serum
albumin, hepatic blood flow, drug metabolizing enzyme activity and glomerular
filtration rate which may alter absorption,
distribution, metabolism and elimination
of drugs, and result in increased sensitivity
to drugs and adverse effects.6 Other than
decreased renal function (creatinine clearance <50 mL/min) or body mass index
(BMI <22), these effects of aging are not
easily identifiable. It is considered wise to
proceed with caution in dosing and carefully monitor for adverse effects.
Cognitive functioning also changes at
varying rates with age. A decline in shortterm memory may cause patients to forget
how and when to take medications or the
reason for taking them.6 Confusion may
result from the degenerative process of
aging, Alzheimer’s disease, or other dementias, but more often occurs due to sleeping
problems, changing drug regimes, discharge from hospital or ADRs.11 Druginduced effects may also cause cognitive
dysfunction such as memory deficits, hallucinations, lethargy, headaches, central
nervous system depression, catatonic states,
delirium and dementia.12 Many classes of
drugs can cause cognitive dysfunction
including antidepressants, antiparkinson
agents, antiepileptics, antipsychotics, benzodiazepines, cardiovascular drugs, corticosteroids, GI drugs, mood stabilizers,
muscle relaxants, NSAIDs, and opioid
analgesics.12 When any of these drugs are
used by elderly patients, the pharmacist
should take particular note of the patient’s
ability to respond and remember.
Socioeconomic issues also affect elderly
patients’ susceptibility to DRPs. One-third
of people over age 65 in Canada live alone
(53% over age 85) and 80% need help for
at least one activity of daily living such as
housework, meal preparation and personal
care.2,4 Paying deductibles or coverage for
nonformulary medications may also be an
issue since 19% of seniors (53% of elderly
women) have low incomes.2 Elderly
patients may therefore need help getting
food, taking or paying for medication, and
reaching health-care services.
Age over 85 has been found to be an
indicator of a greater risk of adverse drug
events, so the very elderly should be identified for greater vigilance.6
Co-morbidities: Thirty-two percent of
noninstitutionalized seniors in Canada
suffer chronic pain or discomfort and
80% have a chronic health condition.2,4
Most common conditions include arthritis-rheumatism (reported by 55%), hypertension (39%), respiratory problems
(24%) and chronic hearing problems,
cataracts and diabetes.4 Having more than
six chronic health problems has been
identified as a risk factor for DRPs in the
elderly.6 The most common drug-related
problem identified in a Canadian study
was “patient not receiving a required drug
for a symptom.”3,8 Having multiple conditions makes DRP identification difficult
because symptoms may be a result of an
existing condition, a new condition, a
natural result of aging or a drug effect.
Symptoms may be unreported due to
embarrassment (e.g. incontinence or forgetfulness), because they are not recognized (e.g. depression), or are attributed to
normal aging (e.g. forgetfulness). Lack of
knowledge about conditions can also lead
to failure to report worsening symptoms
or drug noncompliance.
COUNSELLING GERIATRIC PATIENTS
ABOUT THE AUTHOR
Melanie Rantucci has a doctorate in pharmacy administration. Her research involved
patient counselling for nonprescription drugs
and factors affecting drug misuse in the elderly. She has published numerous articles on
counselling, as well as books which have been
distributed to pharmacists and pharmacy
schools around the world. In addition, Melanie
has presented workshops on patient counselling for practising pharmacists across
Canada and in the U.S.
REVIEWERS
All lessons are reviewed by pharmacists for
accuracy, currency and relevance to current
pharmacy practice.
CE COORDINATOR
Heather Howie, Toronto, Ont.
For information about CE marking, please
contact Mayra Ramos at (416) 764-3879,
fax (416) 764-3937 or mayra.ramos@
rci.rogers.com. All other inquiries about CE
Compliance Centre should be directed to
Karen Welds at (416) 764-3922 or
karen.welds@pharmacygroup. rogers. com.
This CE lesson is published by Rogers Media
Healthcare/Sante, One Mount Pleasant Rd.,
Toronto, Ont. M4Y 2Y5. Tel.: (416) 764-3916
Fax: (416) 764-3931. No part of this CE
lesson may be reproduced, in whole or in part,
without the written permission of the publisher.
CE COMPLIANCE CENTRE • OCTOBER 2004
Symptoms should be identified and
followed-up for possible drug-related
effects, and patients should be educated
about their conditions, symptoms and
treatment.
Polypharmacy: Taking six or more
drugs has been indicated as a risk factor
for DRPs in geriatric patients.6 Fifty-six
percent of the elderly reported using two
or more medications in 1997.4,13 They
also self-prescribe nonprescription medications and herbal remedies, adding to
the complexity of their regimes.
Although most of these drugs are
appropriately prescribed, it has been estimated that seniors receive inappropriate
drug therapy in 11% of physician office
visits.8 Examples of drugs inappropriately
prescribed include long-acting and shortacting benzodiazepines, drugs with anticholinergic effects, and long-term nonselective NSAIDs without cytoprotection.6
On the other hand, beta-blockers, warfarin and antidepressants are commonly
under-utilized or under-dosed.6
Complexity of treatment, i.e. use of
multiple drugs and multiple doses, is
considered among the main causes of
noncompliance in this age group, with an
estimated 3.6 times increase in noncompliance with more than one medication.7
Multiple drug use results in drug interactions and adverse effects. The greater the
number of drugs, the higher the frequency of ADRs, the less likely it is that the
patient has knowledge of the drug, and
the greater the possibility of being admitted to hospital for problems arising from
noncompliance.6,7
Elderly patients’ prescription and nonprescription medications should be regularly reviewed and assessed for indication
and interactions.
Compliance/Adherence: Nonadherence
with medication regimens (both intentional and unintentional) ranges from 26
to 59% in studies of elderly patients.6
While nonadherence rates have not been
found to be significantly different from
other age groups, the causes may be different for the elderly. Reasons in elderly
patients include misunderstanding the
purpose, forgetfulness, intolerable adverse
effects, difficulty hearing or seeing
instructions, inability to take medication
(difficult opening vial, trouble swallowing), belief that drug is not needed, fear
COUNSELLING GERIATRIC PATIENTS
of side effects, perceived lack of efficacy,
and cost.6,7 While personal characteristics
(age, sex, education, marital status, social
class), type of medication and dosage
have not been found to affect adherence
in elderly patients, patient understanding
and comprehension has been found
(along with complexity of treatment) to
have an effect.7
Elderly patients must understand the
purpose of all medications and have
strategies to help with memory and
organization.
Communication: Elderly patients are
faced with a number of barriers to communication including vision and hearing
problems, declining cognitive function,
literacy and attitude. Ninety percent of
people over age 60 have vision problems,
with 6% reporting they cannot see well
enough to read, even with glasses.6 Sixty
percent experience loss of hearing and
sound distortion, with 8% unable to
follow a conversation even with a hearing
aid.6 Often these disabilities are not
immediately apparent and seniors may be
reluctant to acknowledge that they are
unable to hear or see information provided. Inappropriate response to questions,
frequent requests for repetition, turning
head so that ear is closer, squinting, cupping hand behind ear, speaking loudly
and omitting word endings are indicative
of such problems.14 Attention to the environment and use of modified counselling
aids and approaches (e.g. voice amplification) can compensate.
Ability to learn may be affected by
mental characteristics including intelligence, information processing, problem
solving, and approach to learning tend to
decrease with age. Fluid intelligence (perception of complex relations, short-term
memory, abstract reasoning) gradually
decreases with age, whereas crystallized
intelligence (number facility, verbal
comprehension, general knowledge) is
maintained or increases with age.15
Information processing is affected so that
there is increasing difficulty with registering new information and retrieving information.16 A decline in problem-solving
ability may be associated with age due to a
decline in short-term memory, difficulty
organizing complex material, interference
from previous learning, and difficulty disregarding irrelevant aspects.15 In their
3
approach to learning, the elderly also may
be less motivated to learn, less active,
more rigid and cautious.17 These aspects
of cognition and learning in the elderly
can be addressed by teaching strategies
that compensate for this.
Literacy is also an issue when counselling seniors. Many printed materials
require grade eight-level or a higher reading ability, yet seniors have, on average,
lower levels of education than other age
groups. More than one-third of Canadian
seniors have no secondary education, and
more than half are able to perform only
simple reading tasks.4,18 Literacy and education levels will likely improve with the
next cohort of seniors.
Attitudes are an important aspect of
communication with the elderly, from the
pharmacist’s and the patient’s perspective.
Older people may perceive things differently than other age groups because they
adhere to beliefs, values and perceptions
learned in their younger years, such as the
need to hoard medications, suffer in
silence, prudishness about their body functions, and keeping health matters private.19
Their view of health professionals may be
more respectful due to their knowledge and
status, and they may expect an authoritarian approach. However, they may also hold
them to higher standards and have a stereotypical view of how a professional should
look (e.g. male, well-groomed, professional-looking). Elderly patients may also
appear demanding because of their need to
assert their independence, because they are
sad, grieving the loss of a spouse, or lack
social support.
Some pharmacists may see elderly
patients in a stereotypical way, expecting
them to be frail, confused, slow, hard of
hearing, visually impaired and needy.
People fear aging — dealing with the elderly is a reminder of this and may cause
stress in the relationship.14
Cultural Issues: Elderly patients reflect
Canada’s diverse cultural mix, with one in
four Canadian seniors having been born
outside of Canada.4 Most have been in
Canada 35 years or more (60%) and are
acclimatized to Canadian culture. However,
3% of recent immigrants to Canada are
seniors, with Asians being the fastest growing cultural minority.4,20 While the majority of seniors speak one or both of Canada’s
official languages, 4% can speak neither
4
COUNSELLING GERIATRIC PATIENTS
(5% of women and 3% of men).
Seniors from certain cultural groups
may have genetically inherited traits (e.g.
sickle cell anemia in black communities,
thalassaemia among those from the
Mediterranean area, lactose intolerance in
South Asian people) and height, weight
and metabolism may be different such
that it may affect the pharmacodynamics
and pharmacokinetics of drugs.20
Aboriginal seniors are another growing
cultural group in Canada due to better
health and subsequent longevity.4
However, they still have double and triple
the rates of chronic conditions such as
heart disease, hypertension, diabetes and
arthritis compared to other seniors.4
Seniors from cultural minorities may
also have different views about what causes
illness and how to prevent or treat illness,
and different perceptions of health-care
professionals resulting in health behaviours
that may increase the risk of DRPs. They
may not report symptoms (due to side
effects or illness). They may be noncompliant with medications because they treat
chronic illness only when symptoms are
apparent or because they believe Western
medicine is too strong and fear side effects.
They often self-medicate with traditional
medicines that may interfere with prescription medication or be used to replace it.20
ISSUES IN COUNSELLING GERIATRIC
PATIENTS
WHEN PHARMACISTS COUNSEL ELDERLY
patients, they need to recognize a variety
of issues such as ageism, disabilities,
memory and mental deterioration, learning style, and time management which
affect our attitudes and communication.
Ageism: Our attitudes to the elderly
may be complex and dependent on our
own experiences. To a degree, the elderly
are stereotyped as a cohesive group who
are generally ill, rigid in thinking, and failing mentally. However, they are actually a
diverse group, still largely active members
of society. The relationship between the
elderly patient and health-care workers
may be tainted by these stereotypes,21 due
in part, because we deal largely with the
afflicted aged. Consequently, there is a
tendency to provide largely custodial or
palliative therapy to elderly patients and
both groups may approach each other
somewhat negatively.21
CE COMPLIANCE CENTRE • OCTOBER 2004
TABLE 1
Accommodations to Counselling and Compliance for Disabilities14
Disability
Accommodations
All disabilities
Be prepared for feelings
Offer assistance
Do not avoid eye contact
Address patient directly (not care-giver)
Allow extra time
Attend to the environment
Solicit feed-back to ensure understanding
Hearing problems
Do not yell
Enunciate clearly
Speak on side of good ear
Face person directly
Ensure adequate lighting
Use simple sentences to allow for lip-reading
Supplement verbal information with print materials, charts,
diagrams
Visual problems
Identify yourself
Use large print and colour coding or Braille labels as needed
and available
Vary sizes of medication container to help identify different
medications
Use audio-taped information where available
Physical disabilities Provide simple-to-open containers
Remove physical barriers to access – wide doorways and
aisles, remove clutter
Provide seating
Home visit
Since chronic illness is more often the
reason for interactions between healthcare workers and the elderly, both parties
become frustrated because there is no
direct cure. There is uncertainty about
how the condition will progress and be
treated, and the patient may lose faith,
often becoming noncompliant.21
Pharmacists must attempt to see the
individual patient, beyond the elderly
façade.
Disabilities: Elderly patients may
have visual or hearing disabilities that
hamper their ability to communicate. As
well, one-quarter of Canadian seniors
have a long-term disability or handicap
which may affect their ability to access
the pharmacy or physician’s office or
to administer medication themselves.4
Accommodations which can be made are
shown in Table 1.
Emotional accommodations should
also be made.14 The pharmacist may
feel tension, frustration, embarrassment,
aversion or pity when dealing with a disabled patient. The patient may feel frus-
tration, but also irritation with others’
attitudes and may react aggressively or
uncooperatively.
The environment is also important to
consider. Issues such as wheel-chair accessibility, available seating, need for quiet
surroundings and adequate lighting
should be attended to. Counselling materials and medication-dispensing procedures should be adapted to assist patients
to see, hear and understand information.
It is important to allow adequate time for
disabled patients to see, hear, move and
understand. When they feel rushed, their
disability may be accentuated.
When counselling disabled elderly
patients, understanding can be ensured
by asking for feedback in a way that
places the onus on the pharmacist, not
the patient. For example, ask, “So that I
can be sure I have made myself clear,
would you tell me how you are going to
take this medication.”
Pharmacists can also accommodate disabled patients by making home visits. This
relieves nurses and home-helpers from
CE COMPLIANCE CENTRE • OCTOBER 2004
TABLE 2
COUNSELLING GERIATRIC PATIENTS
Counselling Techniques and Tools for Geriatric Counselling
Technique/Tool
Counselling Content
Identify DRPs
History of conditions particularly GI, liver and kidney
Complete drug use
Assess drug-taking ability and factors that may contribute
to noncompliance
Refer patient for assistance as needed
Provide information on side effects
Keep it simple
Use a variety of counselling methods
Provide information in several sessions
Conduct Medication
Reviews
At first patient meeting and when new drugs added
Best by appointment
In pharmacy, clinic, doctor’s office or home
Break into smaller sessions
Use pre-planned format, e.g. “Just Checking”
Focus on issues of importance to drug use in the elderly and
various recommendations
Teaching Strategies
Use strategies to maximize learning ability
Use key questions to enhance learning
Improve Compliance
Actions to reduce each factor that contributes to nonadherence
Family and
Community Support
Educate and involve care-givers about drugs and DRPs
Assist patients to find support if needed
Raise awareness
Offer services to elderly and care-givers
Presentations in community
performing medication-related functions,
improves compliance and reduces DRPs.22
Memory and Mental Deterioration:
Pharmacists may be the first health professional to identify a senior patient experiencing difficulties with memory and
mental functioning. Confusion over how
or when to take medication, whether
medication has been ordered, received or
taken may become apparent when the
pharmacist is counselling the elderly
patient. It may be difficult to approach
the patient directly about this, and
should be done with tact. The patient
may make excuses or deny any problems.
If possible, family members and/or the
patient’s physician should be notified of
concerns about medication problems
resulting from this disability.
There are tests a health professional can
administer to assess mental status such as
the Short Mental Status questionnaire.23 A
series of simple questions are asked (e.g.
name, address, year, month, day of week)
and the patient is asked to do some simple
memory tasks (e.g. name the Prime
Minister, remember three items).
Pharmacists may be in a position, during a
medication assessment, to administer such
a test without offending the patient.
To assist a patient with failing memory, pharmacists can provide dosettes or
blister packaging, and refer patients for
home-care visits to assist in taking medication.
Learning Style and Time: Difficulty
registering new information and retrieving
information can be accommodated by
simple format (i.e. short lists) and uncomplicated content.16 More reinforcement is
needed to learn new material, so material
should be reviewed regularly. Motor tasks
tend to be done more slowly in order to be
accurate, so time should be allowed for
performing and learning tasks like inhaler
use.15 Problem-solving ability can be assisted by providing simple, well-organized
material, relating it where possible to previously learned material.15
COUNSELLING TECHNIQUES AND
TOOLS FOR GERIATRIC COUNSELLING
PHARMACISTS SHOULD BE PREPARED TO
approach counselling geriatric patients
with a variety of accommodations, and
mindful of the potential DRPs that can
5
arise. These are summarized in Table 2.
Counselling Content: It is critical to
gather elderly patients’ complete health
and medication history, including nonprescription medications, herbal and folk
remedies.
Part of an elderly patient’s assessment
should include a discussion of the home
situation, social supports, need for assistance with daily living activities, and ability to take medications, and referrals for
assessment by home-care, dietitian, social
worker, or other health-care professionals
as needed.
Regular medication reviews should be
conducted with elderly patients as conditions, medications and dosage may change.
When DRPs are identified, patients,
their families, care-givers and other healthcare professionals involved should be
informed of the problems and involved in
developing plans to deal with them.
Factors contributing to the noncompliance should be identified and resolved.
When counselling an elderly patient
about a new drug, it is important to consider any assistance the patient may need
in taking the medication, including issues
such as scheduling in relation to other
medications, diet and cognitive abilities.
Side effects should be discussed for
new and continuing medications, as they
can occur at any time. However, it is
important that they be presented in a way
that is not frightening and easily understood. Patients should be encouraged to
report anything unusual, since symptoms
may not be attributed to medication use.
Finally, because there is often so much
information, it should be provided as simply as possible. To avoid overwhelming the
patient, it may be necessary to schedule
several sessions to cover information on
many medications. A variety of counselling
methods (e.g. verbal, print, AV) may
relieve the volume of material. Providing
the patient with a series of questions may
help them organize their learning.
Conducting Medication Reviews:
Medication reviews should be conducted
frequently with elderly patients.
Following a pre-planned format is helpful
in covering the necessary material. The
“Just Checking” program is an ideal tool
for this. Developed in 1999 by the
Canadian Pharmacists Association, in collaboration with member pharmacists, sen-
6
COUNSELLING GERIATRIC PATIENTS
iors and an expert advisory committee,
the program has been extensively used
and tested for efficacy by pharmacists.24,25
It includes a patient screening tool, a
pharmacist assessment tool, and forms for
documenting gathered information, identified problems and follow-up plan. There
are tips on enhancing relations with older
adults, dealing with specific communication issues, and dealing with specific problems such as reading labels and understanding instructions. The program is
available in print or computer-based format from the Canadian Pharmacists
Association (www.pharmacists.ca).
The following recommendations will
guide pharmacists in conducting reviews
to reduce DRPs in the elderly.8,12,26
• Review medication profile of patients
whose clinical condition has changed.
• Monitor regularly and have a high index
of suspicion for adverse reactions (symptoms may present atypically or be attributed to medication) and interactions, particularly with alcohol and psychoactive
drugs and during times of acute illness.
• Assess medications of elderly patients
who fall or develop delirium.
• Drugs (particularly psychoactive drugs)
should be started at the lowest dose possible.
• Aggressively review psychoactive medications and medications that may potentiate effects of psychoactive medications.
• Note extrapyramidal effects of many
medications that may result in falls.
• Watch for drug-induced cognitive
effects and warn patients of this potential.
• Where possible, reduce polypharmacy.
• Avoid drugs with high risk of cognitive
effects such as hypnotics, narcotics, drugs
with anticholinergic effects.
• Note the constipation effects of many
medications.
• Document and communicate information and decisions to health-care team.
• Involve the patient and care-giver in care.
• Ensure the patient can use administration devices.
• Negotiate a regimen the patient can tolerate, manage and afford.
Teaching/Learning Strategies: Because
elderly patients may have cognitive, hearing or vision problems, or may be frail
and unwell, attention needs to be paid to
ways that informational material is provided. The following strategies should be
CE COMPLIANCE CENTRE • OCTOBER 2004
used to maximize the elderly patient’s
ability to learn.
• Decrease distractions such as background noise, to allow patient to focus on
learning.
• Utilize patient’s experiences or knowledge to tie new learning to old.
• Pace the learning by making slower
presentation of material. Allow the
patient to learn in his or her own time.
Pause frequently. Allow time to respond.
• Present material over several sessions.
• Organize material with introduction,
overview, list of facts, summaries.
• Give concrete examples.
• Motivate the patient by asking and
addressing their needs and desires.
Provide rewards.
• Provide the same information visually
(written or pictures) and verbally.
• Provide positive feedback (avoid criticism, provide encouragement).
• Attend to visual and auditory needs e.g.
allow plenty of light, larger print, etc.
• Provide a list of key questions and
answers to help understand their medication (e.g. What is the generic or brand
name of the drug? What is the purpose of
the drug? When should I take the drug?
How is the drug best taken?).
Improving Compliance: To assist
medication adherence in elderly patients,
potential causes of nonadherence must be
identified. During counselling, the pharmacist needs to assess the patient, the
medication and the patient’s environment to determine potential causes of
nonadherence. A patient may have a variety of factors/reasons that will contribute
to nonadherence. Here are suggestions on
how to deal with specific reasons for nonadherence.
• Misunderstanding the purpose or belief
in the medication - Identify the purpose
of the medication on the label and/or
medication chart. Educate the patient on
how the drug will benefit them, and the
potential effects of not adhering, e.g. risk
of stroke if daily ASA is not taken.
• Forgetfulness - Use dosettes or charts
with schedule agreed upon by patient in
relation to their normal daily activities
(e.g. take after walking dog in the afternoon).
• Adverse effects - Identify when adverse
drug reactions are occurring, but also discuss strategies to deal with ones that
affect everyday life such as excessive urination, drowsiness or constipation.
Recommend a change of medication to
the physician if the adverse effects are
dangerous or become intolerable.
• Difficulty hearing or seeing instructions
• Inquire and be alert to signs of difficulties. Provide written materials in larger
print, and speak clearly in a quiet, well-lit
area.
• Inability to take medication (difficulty
opening vial, trouble swallowing) - Make
easy-to-open packaging available. Ask if
the patient has any potential difficulty
taking a medication, with particular
attention paid to physical issues (e.g. putting on a nitroglycerine patch when
hands or shoulders are arthritic).
• Belief that drug is not needed or perceived lack of efficacy - Explain the purpose of the medication, how the drug will
benefit the patient, and the potential
effects of not adhering. If the patient is
still unconvinced, negotiate with them for
a trial period. Suggest ways to identify
that the drug is working, such as regular
blood pressure readings or checking pulse.
Explain how the medication will
improve their quality of life (even if they
feel they have little time left). Suggest
they also discuss this with their physician.
• Fear of side effects - Elderly patients
recognize that drugs have side effects and
that some seniors are over-drugged. They
may have personally experienced overmedication or hear from others who
have. Rather than avoiding a discussion
of side effects, it is better to clearly state
the risk. “One in 100,000” is better than
saying “occasionally” or “a few people.”
Patients often over-estimate the meaning
of these generalizations. It is more important to describe symptoms they should
watch for and what to do if they experience them. Balance this information with
a discussion of the benefits of the drug.
• Cost - Fortunately, in Canada, most elderly patients have some insurance coverage for drugs. However there are some
medications not covered. Delays for
drugs to be listed in formularies mean
that patients will occasionally have to pay
for medications. Clearly justify the benefits (or recommend an alternative that is
covered) and if possible refer the patient
to community resources which may assist
with payment.
CE COMPLIANCE CENTRE • OCTOBER 2004
• Complexity of treatment and number
of drugs - The number of drugs should be
kept to a minimum through regular
medication reviews, discontinuing medications no longer needed, and ensuring
that medications are not added just to
counteract side effects of other medications. Where possible, once-daily dosing
should be promoted. Charts and compliance aids can help where many medications are unavoidable.
Community and Family Support:
The patient’s environment and support of
family, friends and care-givers are important in preventing and reducing DRPs in
the elderly. When possible, supportive
individuals should be included in counselling sessions and provided with written
and verbal information. When problems
are identified, they should be involved in
developing solutions (with the permission of the patient). If there is no such
support available refer the patient to
available community resources.
Raising Awareness: Elderly patients
and their families are not always aware of
the increased risks posed by drug therapy
in elderly patients. Inform them of
potential risks and valuable services pharmacists can provide such as medication
reviews, dosettes or unit-dose packaging,
charts and home visits. Outside of the
pharmacy, make presentations to seniors’
groups, and work with home-care and
nursing agencies to raise awareness of the
risks and benefits of medications and
pharmacy services.
SUMMARY
IT IS IMPORTANT THAT PHARMACISTS ARE
aware and equipped to identify and treat
drug-related problems in the elderly and
are comfortable dealing with this fast
growing group of patients. Elderly
COUNSELLING GERIATRIC PATIENTS
patients and their care-givers are very
appreciative of pharmacy services, and it
can be very rewarding for pharmacists,
provided we are prepared.
REFERENCES
1. Martin-Matthews A. Health Canada. The Health
Transition Fund. Synthesis series: Senior’s health.
Available at www.hc-sc.gc.ca/htf-fass/english/
seniors_en.pdf. Accessed April 6, 2004.
2. Selected Highlights from a Portrait of
Seniors in Canada. Statistics Canada. Available
online at www.statcan.ca/english/ads/89-519XPE/link.htm. Accessed April 6, 2004.
3. Sellors J, Kaczorowski J, Sellors J, et al. A
randomized controlled trial of a pharmacist consultation program for family physicians and their
elderly patients. CMAJ 2003:169(1):17-22.
4. Canada’s Aging Population, report prepared by Health Canada in collaboration with
Interdepartmental Committee on Aging and
Seniors Issues. Available online at www.hc-gc.ca/
seniors.aines/pubs/fed_paper/pdfs/fedpager_e.pdf.
Accessed April 6, 2004.
5. Health care delivery. In: The Merck manual
of diagnosis and therapy. Sec. 21. Special subjects. Geriatric Medicine. Available online at
www.merck.com/mrkshared/mmanual/section21/
chapter293/293b.jsp. Accessed April 7, 2004.
6. Pavlakovic, R. Geriatrics: Special pharmacotherapy considerations. CE lesson in Pharmacy
Practice 2004;20(2).
7. McKim W, Mishara B. Compliance in the
elderly. In: Drugs and Aging. Butterworths,
Toronto, 1987, p.26-31.
8. MacKinnon N. Early warning system – How
vigilant pharmacists can prevent drug-related
morbidity in seniors. Pharmacy Practice 2002;
18(8):40-4.
9. Howard M, Dolovich L, Kaczorowski, Sellors C,
Sellors J. Prescribing of potentially inappropriate
prescription medications for community dwelling
seniors. Presented at the CPhA Conference,
Vancouver, 2003.
10. Forster A, Clark H, Menard A, et al.
Adverse events among medical patients after discharge from hospital. CMAJ 2004;179(3):345-9.
11. Coambs R, Jensen P, Her, M et al. Review of
the scientific literature on the prevalence, consequences, and health costs of noncompliance and
7
inappropriate use of prescription medication in
Canada, 1995, Health Promotion Research,
Toronto, p.46-54.
12. Virani A. Drugdaze – How to prevent or
manage drug-induced cognitive impairment.
Pharmacy Practice 2003;19(10):35-43,47.
13. Seniors and medication misuse, The
Source Newsletter, Prevention Source BC,
Available online at www.preventionsource.bc.ca/
source/003b.html. Accessed April 8, 2004.
14. Rantucci, M. Tailoring counseling. In:
Pharmacists Talking with Patients – A Guide to
Patient Counseling. Williams & Wilkins, Baltimore
1997: p.178-200.
15. Peterson DA. Facilitating education for
older learners. San Francisco, Jossey-Bass, 1983.
16. Moore, SR. Cognitive variants in the elderly: An integral part of medication counseling.
Drug Int & Clin Pharm 1983;17(Nov):840-2.
17. Knox, AB. Adult learning, In: Adult
Development and Learning, San Francisco,
Jossey-Bass, 1977:p.463-9.
18. Powers R. Emergency department patient
literacy and readability of patient-directed
materials. Ann Emerg Med 1988:17(2):124-6.
19. Tindall W, Beardsley R, Kimberlin C.
Communications in special situations. In:
Communication Skills in Pharmacy Practice. 3rd
Ed. Lea & Febiger, Baltimore, 1993: p.141-57.
20. Tjam E, Fletcher P, Chi I. Cultural and gender diversity in health. Stride 2004;6(1):4-9.
21. Coe R, Professional perspective on the aged.
In: Aging, the individual and Society, Ed. Quadagno
J. 1980, St. Martin’s Press, New York. p.472-81
22. Smith P, Andrews J. Drug compliance not
so bad, knowledge not so good: The elderly after
hospital discharge. Age & Ageing 1983;12:336-42.
23. Robertson D, Rockwood K, Stolee P. A
short mental status questionnaire. Can J on
Aging 1982;1(1,2):16-20.
24. Just Checking. Am I getting the most
from my medication? Canadian Pharmacists
Association, 2002. Available from the Canadian
Pharmacists Association, www.pharmacists.ca.
25. Blunt T. Evaluating just checking as a
practice tool for community pharmacists. CPJ
2002;135(1):31-7.
26. Recommendations on drug use in the
elderly. 13th Annual Report of the Geriatric and
Long-Term Review Committee to the Chief
Coroner for the Province of Ontario, 2002.
Pharmacy Connection 2004;11(2):30-1.
QUESTIONS
1. Pharmacists deal with many elderly
patients because of all of the following
EXCEPT
a) There is an increasing number of seniors.
b) Seniors demand extra health services.
c) Seniors consume 28 to 40 % of prescriptions in Canada.
d) The elderly have six medical conditions
on average.
e) Geriatric patients mostly have chronic
conditions.
2. Regarding DRPs in the elderly, the
following is/are TRUE.
a) Increasing age is related to increasing
noncompliance.
b) Up to 75% of seniors have DRPs.
c) Up to 90% of seniors have at least one
inappropriate prescription.
d) Many DRPs are preventable.
e) Both b and d.
3. In Case 1 (in the lesson), which is a factor
contributing to the patient’s DRPs?
a) Literacy
b) Cognitive impairment (forgetting)
c) Self-prescribing
d) Cultural issues
e) Old age
4. In Case 1, which of the following appears
to be an issue for the pharmacist, BB, in
dealing with CK, the elderly patient?
a) Multiple medication use
8
b)
c)
d)
e)
COUNSELLING GERIATRIC PATIENTS
Patient’s hearing problem
CK’s memory
CK’s physical frailty/mobility
All of the above
5. In what way could the pharmacist in
Case 1 accommodate CK and improve
counselling?
a) Allow extra time
b) Yell into the telephone
c) Suggest a home visit (by pharmacist or
home care)
d) Provide written information
e) Both a and c
6. All of the following classes of drugs are
particularly noted to result in cognitive
dysfunction in the elderly EXCEPT
a) Antipsychotics
b) Antilipidemics
c) Muscle relaxants
d) NSAIDs
e) Corticosteroids
CASE 2:
VL is a 4-foot, 98-pound, 87-year-old, Asian
patient. She lives alone and is on the following medications: lorazepam 1 mg HS, digoxin
0.25 mg OD, ASA 325 mg OD, sennosides
OD, acetaminophen with codeine 30 mg q4h
PRN, paroxetine 20 mg OD, hydrochlorothiazide 25 mg AM and multiple vitamin OD.
She seldom comes to the pharmacy, but her
neighbour, and occasionally her daughter,
pick up prescriptions. The daughter calls the
pharmacy to say her mother has just been
released from hospital after a fall causing a
broken ankle and needs all her medications
refilled, all of which are covered by the provincial drug plan.
7. What recommendations would you make
to VL’s daughter?
a) Make sure VL has her lorazepam and
pain medication close to her bedside.
b) Arrange for pharmacist to conduct a
complete review of her medications.
c) Get a three months’ supply of all medications to avoid having to arrange for
someone to pick up prescriptions.
d) Get a dosette to help to organize her
medications.
e) Both b and d.
8. Regarding VL, which issue(s) would the
pharmacist consider when checking for DRPs?
a) Liver and kidney function
b) Cultural issues
c) Possible vision and hearing disability
d) Physical disability
e) All of the above
9. VL’s daughter asks the pharmacist to
provide some information to VL about
paroxetine. The pharmacist should plan
the education session with each of the
Missed something?
CE COMPLIANCE CENTRE • OCTOBER 2004
following considerations EXCEPT
a) Avoid overwhelming detail of information
provided.
b) Schedule a long appointment to provide
all the information in one session.
c) Avoid printed materials in English until
sure of VL’s ability to read English.
d) Provide multiple methods of education.
e) Involve her daughter in educational efforts.
10. Given what is known about VL and her
medications, which reason for noncompliance would be MOST likely for VL?
a) Intolerable side effects
b) Difficulty opening vials
c) Forgetting
d) Complexity and number of drugs
e) Cost
11. The pharmacist arranges for VL’s
daughter to come with her mother to the
pharmacy for a medication review. Which
issue(s) should the pharmacist focus on
in the review?
a) Use of several psychoactive drugs
b) Possible drug-related cause of fall
c) Dosage of medications
d) Possibility to reduce number of medications
e) All of the above
12. All of the following are cultural issues
the pharmacist should consider when
dealing with VL EXCEPT
a) Potential for genetically inherited traits
affecting drug metabolism
b) Potential self-medication with traditional Asian remedies
c) Educational level
d) English language fluency
e) Ability to access physician
CASE 3:
DS is a 72-year-old patient who has
reduced visual acuity, even when wearing
glasses, and suffers from severe arthritis.
13. What accommodations should the
pharmacist consider when counselling DS?
a) Speak loudly
b) Face DS directly
c) Use simple sentences
d) Provide simple-to-open containers
e) Both b and d
14. Which assumptions that the pharmacist
may make about DS are probably NOT true?
a) Very unhappy and anxious
b) Reduced intelligence
c) No sexual interest
d) Financially dependent on children
e) All of the above
15. Health-care workers may feel frustrated and uncomfortable working with
elderly patients due to all of the following
reasons EXCEPT
a) Elderly have mostly chronic illnesses
which have no cure
b) Workers deal with elderly in poor health
and rarely see healthy elderly patients
c) See deteriorating physical and mental
process with age as inevitable
d) Elderly tend to be rude and uncooperative patients
e) Tendency to stereotype elderly as rigid
thinking
16. Which statement(s) is/are TRUE about
learning and cognitive ability in the elderly?
a) Intelligence declines with age.
b) Relating new information to previously
learned information assists problem solving.
c) Providing long lists of information helps
organize material for learning.
d) Reviewing material frequently adds to
confusion.
e) A quick demonstration of inhaler use is
usually sufficient.
17. In Case 3, which counselling techniques
and tools should the pharmacist use?
a) Teaching strategies to maximize learning
ability
b) Involve care-givers or family in education
c) Conduct medication reviews regularly
d) Identify factors that may contribute to
noncompliance
e) All of the above
18. To accommodate the needs of elderly
patients, pharmacists should take all the
following actions EXCEPT
a) Make presentations to community
groups about drug use and the elderly
b) Offer home visits
c) Offer to dispense medications in dosettes
d) Provide written information sheets to all
elderly
e) Use a variety of counselling methods
19. Pharmacist LP is planning a presentation to a local seniors’ group on safe
medication use. What should he/she consider when preparing the presentation?
a) Visual and hearing abilities of audience
b) Negative attitudes to drug use
c) Cultural issues
d) Prepare detailed, printed handouts
about common drugs
e) Both a and c
20. Which drug effects should be focused
on in a medication review with an elderly
patient?
a) Interactions with alcohol
b) Constipation
c) Anticholinergic effects
d) Extrapyramidal effects
e) All of the above
Previous issues of CE Compliance Centre are available at www.pharmacyconnects.com and www.novopharm.com.
COUNSELLING GERIATRIC PATIENTS
1 CEU
1 CE UNIT IN QUEBEC
CCCEP #137-0604
OCTOBER 2004
Not valid for CE credits after June 30, 2007
1.
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5.
a
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Last Name
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d
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First Name
Licensing Prov.
Licence #
a
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c
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d
d
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Email address
Licensing Prov.
Business name
a
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Licence #
Business telephone
Address (❑ Home ❑ Business)
Type of practice
❑ Retail (chain)
❑ Retail (independent)
City
❑ Grocery
❑ Other (specify)
_______________
Province
Postal Code
❑ Owner
❑ Full-time employee
❑ Part-time employee
Year Graduated _______
Feedback on this CE lesson
1. Do you now better understand how to counsel geriatric patients? ❑ Yes ❑ No
2. Was the information in this lesson relevant to your practice?
❑ Yes ❑ No
3. Will you be able to incorporate the information from this lesson
into your practice?
❑ Yes ❑ No
4. Was the information in this lesson... ❑ Too basic
❑ Appropriate ❑ Too Difficult
5. Do you feel this lesson met its stated learning objectives?
❑ Yes ❑ No
6. What topic would you like to see covered in a future issue? _____________________
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